Approach to skin lesions (melanoma)

Question 1

what does ABCDE stand for?

Answer 1

A - asymmetry
B - borders – irregular
C - colour – multiple colours (brown, black, red)
D - diameter ( >6mm)
E - evolving - changing in colour, symmetry, borders, elevation

Question 2

explain the ugly duckling concept

Answer 2

if you have many moles and a new one appears that looks similar to the others, then it is less worrisome vs a new lesion appearing that looks quite different, which would push towards a more sus etiology

Question 3

what are some pt education points re: decreasing melanoma risk?

Answer 3

1. sunscreen - minimum spf 30
2. decrease sun exposure - minimize sunburn and tanning beds
3. know your skin, do regular skin checks
4. UV protective clothing
5. check your RF - skin types, family history, number of moles

Question 4

what is melanoma?

Answer 4

cancer of the melanocytes

Question 5

talk to be about the function of the melanocytes

Answer 5

melanocytes are cells found in the epidermis that when stimulated by UV rays, produces melanin

melanin is protective vs UV radiation damage (built in sunscreen)

Question 6

what does dysplastic nevi mean?

Answer 6

terminology for an atypical mole ➔ benign

some think it can transform into a malignant melanoma - not confirmed

presence of dysplastic nevi does increase risk of developing melanoma

Question 7

explain the pathophysiology of melanoma

Answer 7

1. genetic sus (type 1/2 skin has a specific type of melanin called pheomelanin that does not have the same UV radiation protection properties + UV radiation
2. genetic mutation (mutagenesis) that results in
   - activation of oncogene, inactivation of tumour suppressor genes, increase in GF
3. carcinogenesis

Question 8

s/s of melanoma

Answer 8

> =1 +ve feature of ABCDE

may have s/s of distant mets if not caught in early stages
- LN ➔ LAD
- lungs ➔ SOB, dyspnea
- liver ➔ hepatomegaly
- brain ➔ neurogenic s/s ➔ ALoC, confusion
- bones ➔ bone pain

Question 9

most common sites of mets for melanoma?

Answer 9

1. subcutaneous layers of skin
2. LN
3. distant skin
4. lungs
5. liver
6. brain
7. bones

Question 10

is melanoma a slow growing or aggressive cancer? chance of recurrence?

Answer 10

most aggressive skin ca ➔ once it speads to distant sites it is often incurable

high risk of recurrence

Question 11

average age at dx for melanoma

Answer 11

57Y
middle age/young are most commonly diagnosed

Question 12

how do you workup melanoma? someone who has >=1 positive finding on ABCDE review?

Answer 12

1. history ➔ any family hx of melanoma, sun exposure history, personal hx of cancer or atypical moles
2. physical ➔ evaluate the mole and look for other atypical moles
3. excisional biopsy (elliptical biopsy) to get good margins + full thickness of the lesions ➔ complete genetic testing for BRAF mut for potential targeted therapies
4. consider imaging if there are s/s of metastatic disease
5. if biopsy + for melanoma – consider sentinel LN biopsy +/- LN dissection
6. offer adjuvant therapy: immunotherapy + targeted therapy +/- radiation

if distant mets found: consult palliative and offer immunotherapy, targeted therapy, radiation, and chemo for symptom management